Angela T. Burge

Purpose: Oral corticosteroids (OCS) are recommended for the treatment of exacerbations in people with COPD; however, high cumulative lifetime doses (≥ 1000mg prednisolone-equivalent) are associated with adverse health effects. This issue is well defined in asthma but is less well understood in COPD. The aim of this study was to examine cumulative OCS dispensed to people with COPD over 12 months. Patients and Methods: This was a secondary analysis of data from two randomised controlled trials involving people with COPD followed up for 12 months following pulmonary rehabilitation. Clinical and administrative (respiratory-related hospital admissions and emergency presentations, dispensed OCS and COPD maintenance medications) data were examined to determine cumulative OCS dose relative to the 1000mg threshold and the relationship with clinical features. Results: Of 232 participants (126 females, age mean 68 ± SD 9 years, FEV₁ 53 ± 22% predicted), 48% (n = 112) were dispensed OCS at least once over 12 months. Sixty-two participants (26%) were dispensed ≥ 1000mg. Participants with a high cumulative dose were more likely to have had a respiratory admission (OR 4.1, 95% CI 2.3 to 8.7) and greater breathlessness (modified Medical Research Council scale ≥ 2, OR 2.5, 95% CI 1.3 to 5.0); no relationship with disease severity or maintenance medications was demonstrated. Conclusion: One in four people with COPD were dispensed unsafe lifetime cumulative OCS doses over a period of only 12 months. Further work is needed to determine the magnitude of this issue in COPD and strategies to address exposure to high doses of OCS.

Rationale: New pulmonary rehabilitation models can improve access to this effective but underused treatment for people with chronic respiratory disease; however, cost-effectiveness has not been determined. Objectives: To compare the cost-effectiveness of telerehabilitation, including videoconferencing and synchronous supervision, with standard center-based pulmonary rehabilitation. Methods: Prospective economic analyses were undertaken from a societal perspective alongside a randomized controlled equivalence trial in which adults with stable chronic respiratory disease undertook an 8-week outpatient center-based program or telerehabilitation. Clinical assessment for effectiveness (Chronic Respiratory Disease Questionnaire dyspnea domain score) was undertaken at baseline, after pulmonary rehabilitation, and at 12-month follow-up. Individual-level administrative and self-report healthcare cost data were collected over 12 months after the program (Australian dollars, 2020). Results: There were no between-group differences for effectiveness (Chronic Respiratory Disease Questionnaire dyspnea domain mean difference, −0.2 [standard error, 1.0]; P = 0.61) or total costs ($565 [5,452]; P = 0.92) over 12 months. On the cost-effectiveness plane, 97.4% of estimates fell between the equivalence margins for effectiveness. Application of a range of values for cost margin demonstrated a 95% probability that telerehabilitation was equivalent to center-based pulmonary rehabilitation when the threshold was $11,000. The results were robust to approach and sensitivity and subgroup analyses. The internal rate of return was 134% over 5 years. Program completion (regardless of model) was associated with a significant reduction in total costs in the following 12 months (β, −$17,960; 95% confidence interval, −29,967 to −5,952). Conclusions: This study supports delivery of telerehabilitation as a cost-effective alternative model of pulmonary rehabilitation for people with chronic respiratory disease. Clinical trial registered with the Australian and New Zealand Clinical Trials Register (ACTRN12616000360415).

Background: In adults with serious respiratory illness, breathlessness is prevalent and associated with reduced health-related quality of life. The aim of this review was to assess the impact of breathing techniques on breathlessness in adults with serious respiratory illness.Methods: Electronic databases were searched to identify randomised controlled trials testing breathing techniques (techniques that aim to alter the respiratory pattern, excluding respiratory muscle training) in people with serious respiratory illness. The primary outcome was breathlessness and secondary outcomes were health-related quality of life and adverse events. Two authors independently screened for inclusion, evaluated risk of bias and extracted data.Results: 73 randomised controlled trials were included with 5479 participants, most with COPD or asthma. Breathing exercises (pursed lip and/or diaphragmatic breathing) reduced breathlessness measured by the modified Medical Research Council scale compared to usual care (mean difference (MD) −0.40 points, 95% CI −0.70– −0.11, eight studies, n=323), although the effect did not exceed the minimal important difference. Yoga breathing also improved modified Medical Research Council score compared to usual care (MD −1.05 points, 95% CI −2.45–0.35, three studies, n=175). Breathing techniques consistently improved health-related quality of life in people with COPD and asthma on multiple health-related quality of life measures in comparison to usual care, with effects that generally exceeded the minimal important difference. No adverse events related to breathing techniques were reported.Conclusion: Breathing techniques may improve breathlessness, and consistently improve health-related quality of life, in people with serious respiratory illness. These findings support the use of breathing exercises in the care of people with serious respiratory illness.

Background: In adults with serious respiratory illness, fatigue is prevalent and under-recognised, with few treatment options. The aim of this review was to assess the impact of graded exercise therapy (GET) on fatigue in adults with serious respiratory illness.Methods: Electronic databases were searched to identify randomised controlled trials (RCTs) testing GET (involving incremental increases in exercise from an established baseline) in adults with serious respiratory illness. The primary outcome was fatigue and secondary outcomes were health-related quality of life (HRQoL) and adverse events. Two authors independently screened for inclusion, evaluated risk of bias and extracted data.Results: 76 RCTs were included with 3309 participants, most with a diagnosis of COPD or asthma. Reductions in fatigue measured by the Chronic Respiratory Disease Questionnaire fatigue domain score were demonstrated following GET consisting of aerobic with/without resistance training (mean difference (MD) 0.53 points, 95% CI 0.41–0.65, 11 RCTs, 624 participants) and GET using resistance training alone (MD 0.58 points, 95% CI 0.21–0.96, two RCTs, 82 participants) compared with usual care. Although the mean effect exceeded the minimal important difference, the lower end of the confidence intervals did not always exceed this threshold so the clinical significance could not be confirmed. GET consistently improved HRQoL in people with a range of chronic respiratory diseases on multiple HRQoL measures. No serious adverse events related to GET were reported.Conclusion: GET may improve fatigue alongside consistent improvements in HRQoL in people with serious respiratory illness. These findings support the use of GET in the care of people with serious respiratory illness.

Use of oral corticosteroids (OCS) is an effective treatment recommended for COPD exacerbations however, high cumulative lifetime doses (≥1000mg prednisolone-equivalent) are associated with serious adverse health effects. The importance of this issue is well defined in asthma, but is less well understood in COPD. The aim of this study was to examine cumulative dispensing of OCS in people with COPD in the 12 months following pulmonary rehabilitation. This retrospective study used administrative data for people with a confirmed COPD diagnosis. In 232 participants (126 females, age mean 68 (SD 9) years, FEV1 53 (22) %predicted), 52% (n=120) were not dispensed OCS. 26% (n=62) of participants were dispensed ≥1000mg; 11% (n=7) were dispensed ≥1000mg within the first month of the 12-month study period and 63% (n=39) were dispensed ≥1000mg within the first 6 months. For participants dispensed ≥1000mg, 43% (n=26) were dispensed adequate inhaled corticosteroids (dose sufficient for ≥300 days) for ongoing management. For participants who were dispensed OCS more than once, 88% (n=56/64) were dispensed OCS again within 90 days. 44% of OCS scripts (180/405) were dispensed within 0-1 day of prescription and were for a higher dose (median 750 IQR 300-750mg) compared to scripts filled ≥2 days after prescription (median 300 IQR 300-750mg; p=0.001). Of participants with relevant comorbidities, 36% of participants with diabetes (n=14/25) and 40% of participants with osteoporosis (n=19/35) were dispensed ≥1000mg. People with COPD who have undertaken pulmonary rehabilitation were dispensed potentially unsafe cumulative lifetime doses of OCS over 12 months. Future work is require to explore the clinical importance of this issue in COPD.

Pulmonary rehabilitation is an important treatment for people with chronic respiratory disease [1]. Alternative models of pulmonary rehabilitation, including telerehabilitation, have demonstrated comparable improvements in outcomes such as quality of life and exercise capacity to traditional centre-based (hospital or community) models, but higher completion rates [2]. People with chronic respiratory disease are susceptible to viral infections that are a major cause of acute exacerbations of symptoms, and ultimately impact on quality of life and disease burden [3, 4]. Exacerbations may occur during centre-based pulmonary rehabilitation and can be a barrier to attendance [5, 6].

Shareable abstract A study extended the “can do, do do” concept in people with obstructive airways disease to demonstrate different clinical and movement behaviour characteristics based on quadrant classification, and proposed a treatable traits approach to managementhttps://bit.ly/4cOGlN5

Purpose: The 6-min walk test (6MWT) is commonly used to assess functional exercise capacity in people with chronic respiratory disease in both clinical and research settings. However, two tests are required to achieve accurate results, due to a well-documented learning effect for the 6-min walk distance (6MWD). Whether it is possible to reduce or eliminate the learning effect by optimizing 6MWT instructions is not known. Methods: People with chronic respiratory disease referred to pulmonary rehabilitation undertook two 6MWT with random allocation to modified instructions (fast—walk as fast as possible; n = 46) or usual instructions (far—walk as far as possible; n = 49). The primary outcome was the learning effect, defined as the difference in the 6MWD between test one and test two. Subgroup analyses investigated whether effects varied in those who were naïve to the 6MWT or according to diagnosis (chronic obstructive pulmonary disease, interstitial lung disease, and bronchiectasis). Results: A learning effect was present in both groups, with a mean improvement in the 6MWD on the second test of 14 m in the fast (modified) group (95% CI, 6-22) and 11 m in the far (usual) group (95% CI, 4-19). There was no statistically or clinically significant difference between groups in the magnitude of the learning effect (between-group difference −3 m, 95% CI, −14 to 8). There was no significant effect of naivety to the 6MWT or diagnosis. Conclusion: The current recommended procedures for the 6MWT, including standardized instructions and performance of two tests on each occasion, should be retained.